Page 1 of 3 of Form H IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA Case No.: IN RE: THE GUARDIAN ADVOCACY OF Name of Person with a Developmental Disability ORDER APPOINTING GUAR DIAN ADVOCATE OF THE PERSON (Form H ) Upon consideration of the Petition for the Appointment of Guardian Advocate(s) of the Person, the Court finds that , the person with a developmental disability, has a developmental disability of a nature which requires the appointment of a Guardian Advocate of the person based upon the following findings of fact and conclusions of law, as required by 247 393.12(8), Florida Statutes: 1. The nature and scope - making ability are: 2. The exact areas in which the person lacks decision - making ability to make informed decisions about care and treatment services or to meet the essential requirements for his or her p hysical health and safety are: () to marry () to vote () to travel () to seek or retain employment () to have a driver's license () to determine his or her residency () to consent to medical , dental, surgical care and mental health treatment () to apply for government benefits () to make decisions about his or her social environment or other social aspects of his or her life including but not limited to educational decisions . American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 of Form H 3. The specific legal disability to which the p erson with a developmental disability i s subject to is : 4. The powers and duties of the Guardian Advocate (s) are: ( ) to determine residence; () to consent to medical, dental, and surgical care and mental health treatment; () to make decisions about the social environment or other social aspects of the person with a g decisions concerning education; () to act as representative payee of government benefits or to seek such benefits; () to apply for governmental benefits; t to seek or retain employment. 5. (the person with a developmental disability) shall retain all legal rights except those which are specifically granted to the Guardian Advocate pursuant to court order. 6. T he Petitioner (s) is selected as Guardian Advocate (s) because: Without first obtaining specific authority from the Court, as stated in 247 744.3725, Florida Statutes, the Guardian Advocate (s) may not: a) c ommit the person with a developmental disability to a facility, institution, or licensed service provider wi thout formal placement proceedings, pursuant to Chapter 393, Florida Statutes; b) consent to the participation of the person with a developmental disability in any experimental biomedical or behavior procedure, exam, study, or research; c) consent to the perfo rmance of a sterilization or abortion procedure on the disabled person; American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 of Form H d) consent to termination of life support systems provided for the person with a developmental disability ; e) initiate a petition for dissolution of marriage for the person with development al disability ; or f) exercise any authority over any health care surrogate appointed by any valid advance directive executed by the disabled person, pursuant to Chapter 765, Florida Statutes, except upon further order of this Court. CONSIDERED , ORDERED & AD JUDGED: 1. (Name of Guardian Advocate) is qual ified to serve as Guardian Advocate (s) of the person and is hereby appointed as Guardian Advocate (s) of the Person of , the perso n with a developmental disability . 2. The Guardian Advocate (s) shall exercise only the rights that the Court has found the disabled person incapable of exercising on his or her own behalf, as outlined herein above. Said rights are hereby removed from the per son with a developmental disability and specifically delegated to the Guardian Advocate (s) . 3. Upon taking and filing the prescribed oath , conditioned on the faithful pe rformance of all duties by the G uardian Advocate (s) , letters of Guardian Advocacy shall be issued. DONE AND ORDERED i this d ay of , 20. Circuit Judge Copies furnished to: Attorney a ppointed to represent person with a developmental disability Next of k in of the per son with a developmental disability, if any Health Care Surrogate designated by the person with a developmental disability pursuant to advanced directives, if any Agent appointed by the person with a developmental disability under Durable Power of Attorne y, if any American LegalNet, Inc. www.FormsWorkFlow.com